Operative Technique in Plastic Surgery – Kevin C.Chung

T E C H N I Q U E S
■ Facial Artery Perforator Flap to Repair Perioral
Defect
■ After the flap is marked (TECH FIG 1A) and the artery and perforator are
identified with Doppler, a small amount of local anesthetic with epinephrine
can be injected along the proposed incision line (well away from the
perforators) and allow it to take effect, to minimize oozing for the initial flap
dissection.
■ Incisions are made along the previously marked lines.
■ Low-voltage needle-tip cautery (set at 15) helps precise dissection.
■ Unlike some other perforator flaps in which the perforator is identified first,
with the facial artery perforator flap (where there are multiple perforators
along the course of the vessel), it is best to start the dissection at the distal
end of the flap and carry the dissection down to the SMAS and muscle layer
and start elevating just above the muscles. The terminal branches of the facial
nerve are deep to the muscles and thus protected.
■ The dissection continues toward the facial artery, which is easily visualized
at the inferior, distal end of the flap.
■ The smaller distal perforators are cauterized and divided, and the flap is
dissected superiorly toward the superior perforator (previously identified
by Doppler).
■ No attempt is made to skeletonize the pedicle, but the dissection is continued
until adequate mobility is obtained to allow the flap to rotate into the defect.

TECH FIG 1 • A. Design of perforator facial artery flap.
B. Elevated perforator facial artery flap. C.
Postoperative appearance showing bulky flap that
extends beyond natural subunits of the lip and cheek
and loss of right alar base.
■ Because the perforators are multiple and close together, there may be more
than one perforator in the base of the flap. In addition, a cuff of soft tissue
is needed for adequate venous drainage.
■ The facial artery perforator flap (as compared with perforator flaps
elsewhere) has the benefit of excellent tissue mobility and a tortuous facial
artery, which allow more mobility without skeletonizing or thinning the flap
excessively (TECH FIG 1B,C).
■ Secondary Revision Surgery
■ Small defects can be repaired in a single stage, but larger defects may need
secondary revision (TECH FIG 2).
■ Even though one of the benefits of this type of flap reconstruction is the use
of “like” tissue, it may still be bulky, and secondary debulking to restore the
natural contour may be required.
■ In addition, scars may need to be revised, and restoration of the normal
subunits of the cheek, lip, and nose may require secondary surgery.

TECH FIG 2 • Secondary revision surgeries to restore
right alar base (A) and natural contours of the lip and
cheek (B).
PEARLS AND PITFALLS
Diagnosis
and
suitability
of facial
artery
perforator
flap
■ Assess defect’s suitability for a facial artery perforator flap based on
its location and size. For larger flap requirements, there is a need to
assess adequacy of donor site to avoid deformity or distortion. May
need preliminary tissue rearrangement at the site of the defect to
reduce its size and to conform to subunit principles of repair.
Flap
vascularity
■ Assess vascularity of facial artery and perforators with Doppler
ultrasound.
Flap
design
■ Use templates to design flap.
Pedicle
■ Select perforators that are closest to the defect to allow tension-free
repair.

Technique
■ Mobilize flap as much as needed without skeletonizing the pedicle.
Essential to leave a cuff of soft tissue for adequate venous drainage.
Secondary
procedures
■ Inform patient of possible need of secondary procedures to improve
the contour and restore appropriate subunits for best aesthetic result.
FIG 5 • The patient in TECH FIGS 1 and 2 at 19 months
postoperatively.
POSTOPERATIVE CARE
■ Bacitracin ointment is applied to the suture lines.
■ Sutures are removed at 1 week.
■ Normal smile function is restored once the swelling subsides.
■ Revision surgery, as described above, can be undertaken at 2 to 3 months
postoperatively.
OUTCOMES
■ The facial artery perforator flap is a relatively new addition to our surgical
armamentarium and has the benefit of allowing reconstruction with adjacent,
“like” tissue, giving the best possible aesthetic outcome (FIG 5).
■ Minor revisions to further enhance the aesthetic outcome are generally
required.
COMPLICATIONS
■ Venous congestion may occur if the flap is inadequately mobilized and rotated
and sutured under tension.
■ This can be rectified by additional judicious pedicle dissection, enough to

allow tension-free rotation.
■ If congestion persists, the flap should be returned to its bed and allowed to
equilibrate.
■ Venous congestion can also occur if the pedicle is thinned excessively.
■ This is more difficult to rectify and may need pricking and chemical
leeching.
■ If a congested vein is present at the margin of the flap, this can be cannulated,
and 0.5 cc of blood can be intermittently allowed to drain. This is more
effective than simple pricking, as the whole venosome is decompressed. This
technique can be used for any congested flap, and typically after a few hours,
the venous drainage equilibrates.
REFERENCES
1. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body:
experimental study and clinical applications. Br J Plast Surg. 1987;40:113-141.
2. Hyakusoku H, Yamamoto T, Fumiiri I. The propeller flap method. Br J Plast
Surg. 1991;44:53-54.
3. Park C, Lineaweaver WC, Buncke HJ. New perioral arterial flap: anatomic
study and clinical application. Plast Reconstr Surg. 1994;94:268-276.
4. Saint-Cyr M, Wong C, Schaverien M, et al. The perforasome theory: vascular
anatomy and clinical implications. Plast Reconstr Surg. 2009;124:1529-1544.
5. Gunnarsson GL, Jackson IT, Westvik TS, et al. The freestyle pedicle
perforator flap: a safe reconstructive option for moderate sized facial defects.
Eur J Plast Surg. 2014;37:315-318.
6. Gunnarsson GL, Thomsen JB. The versatile modiolus perforator flap. Plast
Reconstr Surg Global Open. 2016;4(3):e661.
7. Hofer SOP, Posch NA, Smit X. The facial artery perforator flap for
reconstruction of perioral defects. Plast Reconstr Surg. 2005;115:996-1003.

40
CHAPTER
Facial Artery Musculo-
Mucosal (FAMM) Flap
Julian J. Pribaz and Simon G. Talbot
DEFINITION
■ The FAMM flap is an acronym for facial artery musculomucosal flap.
■ It was derived based on the principles of combining a nasolabial and buccal
mucosal flap, to create an intraoral axial flap, centered on the facial artery.1
■ It is very versatile and can be reliably based superiorly (retrograde flow) or
inferiorly (antegrade flow), to reconstruct a wide variety of difficult defects
within the oral and nasal cavities.
ANATOMY
■ The FAMM flap is an axial flap containing the facial artery with its
accompanying venous plexus, with a small amount of surrounding buccal fat,
buccinator muscle, submucosa, and mucosa. It can be thought of as an intraoral
and mirror-image version of an axial nasolabial flap.
■ Arterial anatomy
■ The facial artery provides a rich blood supply to the lower central part of the
face and neck.
■ It is a branch of the external carotid artery, and after giving off several
cervical branches, it enters the face by hooking around the lower border of the
mandible at the anterior edge of the masseter muscle (FIGS 1 and 2).
■ It follows a tortuous course through the cheek, passing upward and medially
toward the oral commissure.
■ It traverses deep to the superficial muscles of facial expression—the risorius,
the zygomaticus major and minor, and the superficial lamina of the orbicularis
oris muscles.
■ It lies superficial to the buccinator, the levator angulioris muscle, and the

lateral edge of the deep lamina of the orbicularis oris muscle, and it has a
variable relationship to the levator labii superioris muscle.
FIG 1 • Anatomy of facial artery.
■ It gives off the inferior and superior labial arteries (through which it connects
with the contralateral side), as well as multiple perforators to the cheek skin
and mucosa. In the cheek, it also anastomoses with the buccal and transverse
facial vessels.
■ It continues superiorly as the angular artery, giving multiple perforators to
the nasal alar and sidewall, and terminates near the medial canthus where it
anastomoses with branches from the dorsal nasal, infratrochlear, and
infraorbital vessels.2
■ Venous Anatomy
■ The main facial vein does not run with the artery but is located more laterally
in the cheek and approaches the facial artery near the angle of the mandible.
■ Nonetheless, the FAMM flap has an excellent venous outflow and rarely
becomes congested due to a “syncytial” type of venous plexus within the
submucosa, which connects not only to the facial vein but also to pterygoid
plexus and maxillary vein.
■ Due to its intraoral design, the FAMM flap spares the superficial and most
important muscles of facial expression and their nerve supply, as well as the
overlying skin, thus minimizing deformity.3
■ The FAMM flap is usually 1.5 to 2 cm in width and can be 8 cm in length, but
it is key that the facial artery traverses the entire flap. Although from the
vascular point of view the flap could certainly be made wider, this would create

too large an intraoral defect, leading to contracture.
FIG 2 • Schematic of the course of the left facial artery
through the cheek passing between the superficial
muscles of facial expression and buccinators.
Contralateral intraoral view of proposed right FAMM
flap.
■ The flap is designed anterior to Stensen duct.
■ The FAMM flap can be based superiorly (where the blood flow is retrograde)
or inferiorly (where the blood flow is antegrade), thereby increasing its
versatility.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The FAMM flap may be indicated in patients with a wide array of relatively
small (yet difficult to repair) defects and deformities within the oral cavity,
including small defects in hard and soft palate, alveolus, buccal sulcus, floor of
mouth, tongue, and tonsillar fossa. It can also be used to reconstruct defects of

the upper and lower lip vermilion. In addition, the flap has been used to
reconstruct intranasal mucosal defects.4,5
■ The patient needs to be carefully evaluated and the problem in question
accurately assessed according to its location and size to determine if a pedicled
FAMM flap (with maximum size 2 × 8 cm) can be used for the reconstruction.
■ An intact facial artery, detected by Doppler examination, is crucial, as is the
lack of scars from previous procedures along the course of the flap.
Superiorly or Inferiorly Based FAMM Flap?
■ A superiorly based FAMM flap is considered for defects involving the hard
palate, upper alveolus, antrum, upper lip sulcus, and vermilion and for
restoration of nasal lining (FIG 3).

FIG 3 • Superiorly based FAMM flap may be used to
repair defects of (1) the hard palate, alveolus, (2)
maxillary antrum, upper lip sulcus and vermilion, (3)
nasal lining.

FIG 4 • Inferiorly based FAMM flap may be used to
repair (1) floor of mouth, lower lip sulcus, and vermilion,
(2) soft palate and tonsillar fossa, and (3) hard palate.
■ An inferiorly based FAMM flap would be considered for defects in the floor of
mouth, tongue, lower lip sulcus and vermilion, tonsillar fossa, and soft palate
(FIG 4).
Intact Upper Jaw Dentition vs (Unilateral or Bilateral) Edentulous
Alveolar Cleft Deformities?

■ This will determine the type of FAMM flap that may be used; with an intact
dentition, a superiorly based flap to repair a palatal defect cannot be used as the
flap cannot traverse an intact dentition. However, it may be possible to repair a
palatal defect with an intact dentition by using an inferiorly based flap, which
is brought around the maxillary tuberosity.
■ Reconstruction of fistulas and other through-and-through defects requires
consideration of both lining and coverage requirements. The lining may be
achieved with local turn-in flaps, but this may then make the defect too large
for coverage with a FAMM flap. Occasionally, two FAMM flaps may be
considered—one for lining and another for coverage.
SURGICAL MANAGEMENT
■ Preoperatively, a careful assessment needs to be made whether the FAMM flap
is appropriate for the needs of the repair based on the size and location of the
defect within the oral or nasal cavity.
■ A decision based on the problem being addressed will need to be made
whether the FAMM flap will be superiorly or inferiorly based.
■ Defects that are too large, or prior surgeries and scar, may preclude the
successful use of the FAMM flap, and an alternative method of repair will be
required.
Preoperative Planning
■ It is essential to map out the course of the facial artery. The artery is easily
palpated at the angle of the mandible, and then its course can be mapped out
with a Doppler ultrasound, both extra- and intraorally.
■ It is important to remember that the facial artery has a tortuous course through
the cheek to allow for the tissue mobility for facial movement and expression.
■ Its course is well anterior to the Stensen duct and has a roughly “boomerang-
shaped” course, passing obliquely toward the oral commissure and then more
vertically toward the alar base.
Positioning
■ The procedure is performed under general anesthesia with the patient supine
and the operating table rotated 90 to 180 degrees away from the anesthesia
team.
■ For intraoral work, a nasal endotracheal tube is best, but an oral endotracheal
secured to the contralateral side of the mouth or with a Dingman retractor

securing the tube in the midline can also be used.
■ Silk traction sutures are placed on the ipsilateral upper and lower lips and
commissure (taking care not to injure the facial artery as it passes close to the
commissure).
■ The boomerang-shaped flap, which is 1.5 to 2 cm in width, is then marked out
centered on the Doppler-identified facial artery.
Approach
■ As previously mentioned, the selection of a superiorly or inferiorly based flap
will depend on the problem at hand.
■ Local anesthetic with epinephrine may be injected, but only into the distal part
of the flap for easier dissection of the facial artery. Vasoconstriction should be
allowed to take effect before commencing the flap dissection.
T E C H N I Q U E S
■ Dissection commences at the distal end of the flap, with an incision through
the mucosa, submucosa, and buccinator muscle. The facial artery is
identified, ligated, and divided. It is important that the facial artery itself and
not a branch has been identified before proceeding with the rest of the flap
harvest.
■ It is helpful to leave the tie on the cut facial artery in the flap long and use it
to apply traction to facilitate the dissection.
■ The rest of the flap is then scored, and the dissection proceeds just deep to
the facial artery, taking only a small cuff of buccinator and orbicularis oris
muscles near the commissure.
■ The flap is about 1 cm in thickness and contains the facial artery along its
entire length, which designs a long axial flap with length/width ratios as high
as 5:1.
■ The flap dissection continues until an adequate length has been achieved
(often 8–9 cm), and is either based superiorly or inferiorly, leaving a mucosal
pedicle base to ensure adequate venous drainage.
■ The facial vein is not seen in the dissection and hence not harvested with the
flap. However, there is adequate venous outflow via an extensive submucosal
venous plexus, and the flap does not appear congested.
■ The arc of rotation for superiorly based flaps is at the gingivobuccal sulcus

and, for inferiorly based flaps, the retromolar trigone.
■ Superiorly based flaps usually rotate 90 degrees when used for upper lip
sulcus and vermilion reconstruction or to traverse an alveolar edentulous
space to the palatal defect. It is preferable not to tunnel the flap but simply
incise the mucosa from the base of the flap to the lip or palatal defect. The
inset should be under no tension (TECH FIG 1).
■ For nasal reconstruction, superiorly based flaps rotate 180 degrees and are
tunneled through the gingivobuccal sulcus to the floor of the nose. To
adequately inset these flaps into the nose, lateral rhinotomy incisions are
required. Because of the bulk of the flap at its base, there will be temporary
nasal airway obstruction, until the flap is divided and inset at 2 to 3 weeks.
■ Inferiorly based flaps rotate at the retromolar trigone and may be used to
repair tonsillar, floor of mouth, and tongue defects. They are also used to
repair lower lip sulcus and vermilion. Again, it is best not to tunnel the flap,
and it is safer to incise the mucosa between flap base and defect and inset the
flap with no tension.
■ When inferiorly based flaps are used to reconstruct posterior hard palate or
soft palate defects, the bulkiness of the flap base may necessitate the use of a
temporary bite block to prevent bite injury to the pedicle.
■ A modification of the FAMM flap has been developed for use in palatal
reconstruction where there is an intact dentition (precluding use of a
superiorly based flap) and to avoid using a bite block with inferiorly based
flaps. This involves the elevation of a mucoperiosteal palatal flap, which is
the width of the FAMM flap and which is raised from the base of the FAMM
flap as a turnover flap, which is dissected to approximately 8 mm of the
palatal defect and used as a large nasal turn-in lining flap. Raising such a flap
achieves two goals: providing nasal lining and creating a big enough trough
to allow the FAMM flap to be inlayed, thus masking its bulky base and
allowing a single-stage reconstruction without the need for a bite block.6
■ The repair of the cheek donor defect is performed in layers, using absorbable
sutures for the buccinator and mucosa (TECH FIGS 2 and 3).

TECH FIG 1 • Superiorly based FAMM flap for repair
of a palatal fistula. A. A 15-year-old female with palatal
fistula and alveolar gap. B. Design of superiorly based
right FAMM flap. C. Elevated superiorly based FAMM
flap. D. Repaired palate at 3 weeks.
TECH FIG 2 • A. Inferiorly based FAMM flap for repair
of a large palatal defect. B. A 17-year-old male with
large palatal defect and intact left dentition with no
alveolar gap. C. Appearance of postinferiorly based
FAMM flap—note the bulk at flap base requiring a bite
block.

TECH FIG 3 • Inferiorly based FAMM flap used for the
repair of palatal fistula. A. A 61-year-old female with
palatal fistula post tumor excision. Note the intact
dentition. B. Design of inferiorly based FAMM flap and
anteriorly based mucoperiosteal palatal flap from base
of FAMM flap to edge of defect. C. Mucoperiosteal
palatal flap raised and used to repair nasal side of
defect. D. Inferiorly based FAMM flap raised. E. FAMM
flap inset.
PEARLS AND PITFALLS
Techniques
■ It is essential to have the facial artery traverse the entire length of this
long, thin flap to avoid ischemia at the distal tip and consequent
failure of the reconstruction.
■ Do not skeletonize the flap on the facial artery, as the venous
drainage is by tiny venous plexus vasculature throughout the flap. It
is important to leave some soft tissue around the base of the flap to
ensure adequate venous drainage.
■ Maintaining the proper plane of dissection should avoid injury to the
branches of the facial nerve, whose terminal branches lie directly
beneath the facial artery during the dissection, and they can be gently

dissected away from the artery.
Limitations
■ A limitation to the FAMM flap is its size. Although larger intraoral
cheek flaps can be designed on the facial artery, secondary donor-site
problems such as cheek contractures may arise, so the use of flaps
that are too wide should be avoided.
POSTOPERATIVE CARE
■ It is essential to maintain good oral hygiene with regular mouth washes.
■ The patient is commenced on a soft diet, which is advanced over the first
week.
■ The patient is counseled that there will be swelling in the cheek with some
limitation of normal smile function. This is temporary and full and normal
smile function returns once all swelling has subsided at 2 weeks.
■ Any sutures that have not dissolved in the first 10 days can be removed.
■ No special rehabilitation is required.
OUTCOMES
■ The FAMM flap provides a versatile solution for a wide range of intraoral
reconstructive needs.
■ When based superiorly, the FAMM flap can be used to repair mucosal defects
in the anterior hard palate, alveolus, maxillary antrum, nasal floor and septum,
and upper lip sulcus, and vermilion.
■ When based inferiorly, the FAMM flap can be used to close defects in the
posterior hard palate, soft palate, tonsillar fossa, tongue, floor of mouth, lower
lip sulcus, and vermilion.
■ When used for palatal cleft defects, it eliminates the need for a palatal
prosthesis.
■ The base of the flap is thick, and when used for palatal, nasal, and alveolar
defects, the flap base will need to be thinned or divided (which can be safely
done at 2 weeks) and inset, to restore the nasal airway in cases of nasal lining
reconstruction or contour restoration of the alveolus to allow dental
rehabilitation.
COMPLICATIONS
■ It is essential that the entire flap, especially its distal end, remains well
perfused. This is the part which is most needed to complete the repair. This is
achieved by ensuring maximum axiality with the facial artery running along the

entire length of the flap.
■ With the use of larger flaps, the patients may experience some tightness and
contracture at the donor site, requiring scar release with one or two Z-plasties
of the contracted scar.
REFERENCES
1. Pribaz JJ, Stephens W, Crespo L, Gifford G. A new intraoral flap: Facial
Artery musculomucosal (FAMM) flap. Plast Reconstr Surg. 1992;90:421-429.
2. Niranjan NS. An anatomical study of the vascular pattern of the facial artery.
Ann Plast Surg. 1988;21:14.
3. Dupoirieux L, Plane L, Gard C, et al. Anatomic basis and results of the facial
artery musculomucosal flap for oral reconstruction. Br J Oral Maxillofac Surg.
1999;37:25.
4. Pribaz JJ, Meara JG, Wright S, et al. Lip and vermilion reconstruction with the
facial artery musculomucosal flap. Plast Reconstr Surg. 2000;105(3):864-872.
5. Duffy FJ Jr, Rossi RM, Pribaz JJ. Reconstruction of Wegner’s nasal deformity
using bilateral facial artery musculomucosal flaps. Plast Reconstr Surg.
1998;101:1330.
6. Matros E, Swanson EW, Pribaz JJ. A modification of the facial artery
musculomucosal flap for palatal reconstruction in patients with intact dentition.
Plast Reconstr Surg. 2010;125:645.

41
CHAPTER
Free Flap for Hemi-Tongue
Reconstruction
Carrie K. Chu and Periong Yu
DEFINITION
■ The tongue is a highly functional organ responsible for speech, deglutition,
taste, and airway protection.
■ Glossectomy defects following oncologic resection represent the most
common indication for oral cavity reconstruction.
■ Glossectomy defects can be partial, subtotal, or total. In general, defects that
exceed one-third of the tongue or include significant floor of mouth resection
usually require free flap reconstruction. Small defects may be closed primarily
or skin grafted.
■ Goals of partial glossectomy reconstruction include provision of soft tissue
coverage, restoration of intelligible speech, restoration of oral intake,
maintenance of patent airway, and separation of the oral cavity from the
structures of the neck when required. Re-establishment of sensation is a
secondary but important goal.
ANATOMY
■ The tongue is composed of two anatomic components. The anterior two-thirds
within the oral cavity is the oral (or mobile) tongue, whereas the posterior third
within the oropharynx is the base of the tongue. The boundaries of the base of
the tongue include the circumvallate papillae anteriorly, the glossoepiglottic
folds laterally, and the vallecula and the lingual aspect of the epiglottis
posteriorly (FIG 1A).
■ General sensation to the anterior two-thirds of the tongue is supplied via the
lingual nerve (CN V3). The chorda tympani (CN VII), which accompany the
lingual nerve, are responsible for taste.

■ Taste and sensation for the posterior one-third tongue derive from the
glossopharyngeal nerve (CN IX).
■ Motor innervation of the intrinsic and extrinsic tongue musculature is via the
hypoglossal nerve (CN XII), with the exception of the vagus nerve (CN X) for
the palatoglossus muscle. The floor of the mouth, the ventral sulcus, and the
lateral gutter facilitate the excursion of tongue muscle for its intelligent
functions. The tip of the tongue easily touches the palate for precise
pronunciation (FIG 1B).
■ The lingual arteries, branches of the external carotid artery, provide vascular
supply to the tongue. A secondary blood supply arises from the tonsillar branch
of the facial artery and the ascending pharyngeal artery. Venous drainage is via
the lingual veins into the internal jugular vein.
PATHOGENESIS
■ Oral cavity and oropharyngeal cancers, including squamous cell carcinoma
and minor salivary gland carcinomas, are the main indications for
hemiglossectomy.
■ Risk factors for oral cavity and oropharyngeal cancers include tobacco and/or
alcohol use, human papillomavirus infection, elderly age, male sex, inhaled
environmental or occupational exposures, and poor oral/dental hygiene.
FIG 1 • A. Anatomy of the tongue. The tongue is
composed of the anterior (mobile) tongue and the
posterior base of tongue separated by the circumvallate
papillae. B. The ventral sulcus allows the tip of the

tongue to touch the palate. The frenulum marks the
midline of the ventral tongue. The lingual vessels travel
on the ventral surface of the tongue and are close to the
midline near the tip.
■ Oral tongue cancers are typically treated with up-front surgical resection,
whereas base of tongue cancers are frequently managed with neoadjuvant
radiation followed by surgery as indicated.
■ Glossectomy potentially compromises tongue function including speech,
deglutition, and taste. The base of the tongue is more important for swallowing
function, whereas the oral tongue is more important for speech and food
manipulation. Restoration of these functions while preserving airway patency
represents the main objective of hemiglossectomy reconstruction.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Symptomatology review should be performed including pain, swallow
dysfunction, oral intake status, speech alteration, otalgia, paraesthesias, altered
tongue mobility, and airway obstruction.
■ History of neoadjuvant therapies should be noted. In cases of recurrence,
records concerning prior surgical history, including neck dissection, should be
reviewed in detail.
■ The surgeon should be aware of factors that may compromise recipient vessel
availability including radiation and prior cervical lymphadenectomy.
■ Medical comorbidities and substance abuse history are both highly prevalent
in this patient population.
■ Occupation, hobbies, physical activity level, and hand dominance should be
queried to select an optimal donor site.
■ Head and neck examination should include the following elements:
■ Neck range of motion
■ Palpation of the facial artery
■ Quality of neck skin
■ Interincisal opening distance
■ Dental hygiene and presence of caries
■ Cranial nerve function (V, VII, XII)
IMAGING

■ Computed tomography studies with contrast are reviewed for primary tumor
dimensions including extension past midline, adjacent structures, and neck
vessel patency.
SURGICAL MANAGEMENT
■ Partial glossectomy defects smaller than one-third of the native tongue without
a floor of mouth defect can typically be reconstructed with primary closure or
skin grafting.
■ The latter may exhibit partial graft loss but ultimately will serve as a biologic
dressing that allows for eventual mucosalization.
■ Hemiglossectomy defects benefit from free flap reconstruction using a thin,
pliable flap to avoid restricting functional tongue mobility.
■ These goals are distinguished from those associated with subtotal or total
glossectomy, where the objective is to render a bulky flap reconstruction that
provides adequate palatal contact to avoid aspiration and enhance speech
intelligibility.
■ Consideration should also be given to sensory reinnervation.
■ Resection of the floor of the mouth combined with neck dissection creates a
communication between the oral cavity and the neck along the lingual cortex
of the mandible.
■ These defects, even if they involve less than one-third of the tongue, are best
reconstructed with a flap to minimize the risk of infection and fistula
formation, which can potentially delay crucial adjuvant therapy.
■ The pectoralis major muscle or myocutaneous flap is a pedicled option for
hemiglossectomy reconstruction. Its bulk, potential tethering and downward
retraction are disadvantages for hemiglossectomy reconstruction. The
functional outcomes are usually compromised.
■ Therefore, it is usually reserved for salvage after a failed free flap
reconstruction or for use in high-risk cases deemed unsuitable for free flap
reconstruction.
Preoperative Planning
■ The potential functional impairment should be thoroughly discussed with the
patient and family because these deficits will not only significantly affect their
quality of life but their profession as well.
■ Referral for dental extractions in preparation for flap inset and adjuvant
radiation may be appropriate if significant caries or nonviable teeth are

identified.
■ The availability of blood products based on preoperative type and cross should
be confirmed.
■ Potential donor-site assessment should be carried out including soft tissue
thickness and quality of the upper extremity and thighs.
■ Hand dominance should be documented.
■ The radial and ulnar aspects of the forearm should be assessed for hair
growth. A less hairy skin flap is preferred.
■ Flap choices
■ In patients with very thin thighs, the anterolateral thigh flap is the first choice
due to its minimal donor-site morbidity with the exception of young female
patients.
■ Otherwise, the ulnar artery perforator flap is the first choice followed by the
radial forearm flap as the ulnar artery flap creates a less conspicuous donor-
site scar.
■ The most common flaps for hemiglossectomy reconstruction are described in
this chapter, but consideration may be given to numerous alternative donor-
site options that would provide thin, pliable tissue to meet the goals of
reconstruction.
• These include, but are not limited to, lateral arm, profunda artery perforator,
anteromedial thigh, and medial sural artery perforator flaps.
■ Preoperative nutritional status should be evaluated.
■ Some patients may have lost significant weight due to pain and inability to
consume oral diet.
■ A percutaneous gastrostomy feeding tube may be necessary to provide
adequate nutritional support before surgery.
■ Antibiotic prophylaxis is administered before incision. For defects involving
the aerodigestive track, 3 g of ampicillin/sulbactam is our antibiotic of choice,
which is redosed every 6 hours.
Positioning
■ The patient is placed in supine position, typically with the operating table
reversed by 180 degrees.
■ Placement of an underbody warmer avoids physical interference with multiple
surgical sites.
■ The dominant arm is tucked, while the contralateral potential donor arm is

prepped circumferentially toward the axilla.
■ The arm is secured to the chest drapes to provide room for the extirpative
team.
■ It is then placed on an arm board for flap harvesting.
■ The thighs are also prepared for potential thigh flap or as a skin graft donor
site.
■ The lower abdomen/groin may be prepared as a full-thickness skin graft donor
site to cover forearm flap donor-site defect.
■ A two-team approach is possible when harvesting a thigh-based flap.
■ With a forearm flap, flap elevation may require delay until the extirpative
team completes the resection and neck dissection.
T E C H N I Q U E S
■ Recipient Site Preparation
■ While waiting for margins, the defect is assessed, and recipient vessels are
dissected out.
■ A Dobhoff feeding tube is inserted into the stomach intraoperatively if
percutaneous gastrostomy is not indicated.
■ The length of the surgical defect is measured from the tip of the remaining
tongue to the posterior limit, which can be in the base of the tongue or
immediately above the epiglottis (TECH FIG 1A). In the latter case, there
will also be a defect in the lateral pharyngeal wall.
■ The viability of the remnant tongue should be assessed as well. However,
any debridement should be conservative and limited to tissue that is
definitively nonviable. Marginal areas may benefit from time for recovery
and demarcation postoperatively.
■ The width of the defect includes the tongue as well as the floor of the mouth.
A flap width of 6 to 8 cm is usually required to adequately recreate the lateral
sulcus and provide enough surface area coverage.
■ A neck dissection is commonly performed along with a glossectomy.
■ Extra soft tissue is included in the flap design to obliterate any
submandibular or upper neck dead space.
■ The transected end of the lingual nerve should be explored for potential

sensory reinnervation (TECH FIG 1B).
■ The lingual nerve is the optimal recipient for sensory reinnervation of the
neotongue compared to other options such as the inferior alveolar nerve
and the greater auricular nerve.
■ It is usually 2 mm in diameter and can be found along the lingual cortex
and anterior to the angle of the mandible.
■ The lingual artery is often exposed and divided during glossectomy. With a
diameter between 2 and 2.5 mm in most cases, the lingual artery represents
an ideal recipient target.
■ The facial artery is often divided as well during a neck dissection and can
be used as a recipient artery. Its diameter is similar to that of lingual artery.
■ The artery is dissected back to its origin from the external carotid artery
and brought under the posterior belly of the digastric muscle (TECH FIG
1C), which can be divided if it facilitates improved vessel access.
■ The curved portion of the artery is removed to allow for unimpeded inflow,
leaving only a 1-cm stump on the external carotid artery.
■ Sometimes, the lingual and facial arteries share a common trunk, which may
be more suitable as a recipient vessel as the vessels may become small after
the bifurcation. The superior thyroid artery is usually much smaller in
Western populations and is usually undisturbed during ablative surgery, thus
less desirable as a recipient vessel.
■ The author’s preferred recipient vein is a branch of or the common facial
vein stump on the internal jugular vein depending on the flap vein size. A
vein coupler or flow coupler is used for end-to-end anastomosis (TECH FIG
1D).

TECH FIG 1 • A. A hemiglossectomy defect can
extend from the tip of the tongue to the base of the
tongue, sometimes all the way to the epiglottis. The
length of the defect usually varies from 6 to 12 cm. B.
The transected lingual nerve (white arrow) can be
found on the lingual surface of the mandible near the
angle. The hypoglossal nerve (yellow arrow) can be
found immediately below the digastric muscle. C.
Common recipient vessels include the lingual artery,
facial artery (white arrow), the common facial vein
(yellow arrow), and its branches. D. A vein coupler is
used for end-to-end venous anastomosis to a facial
vein branch. E. An incision is made from the apron
neck incision toward the midclavicle to explore the
transverse cervical vessels. F. These vessels are
immediately above the clavicle and have good size

match with the flap vascular pedicle.
■ If no facial vein branches are available, an end-to-side anastomosis on the
internal jugular vein itself is a viable option.
■ If the internal jugular vein is also unavailable, the external jugular vein, if it
remains in good condition, is the next choice.
■ The transverse cervical vessels are usually available even in the vessel-
depleted neck1 and can be easily reached with a radial forearm flap or
anterolateral thigh flap without the need for vein grafting (TECH FIG
1E,F).
■ Finally, the internal mammary vessels and the use of a cephalic vein turn-
up can serve as the last resort.
■ Flap Harvest
Radial Forearm Free Flap
■ A flap with a width of 6 to 8 cm and length of 10 to 12 cm is usually
required for a true hemiglossectomy defect.
■ The flap width is centered on the radial vessels with the distal margin at the
wrist crease.
■ Flap elevation is performed under tourniquet control.
■ The use of the venae comitantes as outflow is preferable to the cephalic
vein,2 because the distance of the cephalic vein from the radial artery may
unnecessarily increase the flap width or the cephalic vein is positioned at the
edge of the flap, not ideal as venous outflow (TECH FIG 2A).
■ In rare occasions, the venae comitantes of the radial forearm flap are
inadequate. A small transverse incision at the wrist crease is made first to
explore the venae comitantes (TECH FIG 2B). If one of these veins is at
least 1 mm in diameter, the cephalic vein may safely be excluded.
■ Otherwise, the flap design is shifted laterally to capture the cephalic vein.
■ Suprafascial dissection is preferable. The thenar branch of the superficial
radial sensory nerve can be preserved with suprafascial dissection (TECH
FIG 2C).
■ At the midforearm level, the lateral antebrachial cutaneous nerve can be
found near the midline. This nerve can be included in the flap for sensory
reinnervation.

■ In most hemiglossectomy cases, a small dead space is created under the
mandible. Inclusion of some adipofascial tissue from the proximal forearm is
useful to fill the dead space.
■ The proximal forearm skin flaps can be elevated below the subdermal
plexus, leaving the subcutaneous tissue attached to the flap and the vascular
pedicle (TECH FIG 2D).
■ Alternatively, this adipofascial flap can be based on a proximal perforator
(TECH FIG 2E). This addition represents an important measure to
decrease risk of infection and fistula formation.
■ As the venae comitantes are usually no larger than 1.5 mm in diameter
before they converge, the vein is usually taken above the convergence, where
the diameter is usually greater than 2.5 mm.
■ Once the flap and the vascular pedicle are completely dissected, the
tourniquet is released to perfuse the flap and the hand for several minutes
before dividing the pedicle.
■ For donor-site coverage, a full-thickness skin graft from the groin area is
preferred to split-thickness skin graft.
■ Suprafascial dissection and full-thickness skin grafting can achieve
superior donor-site healing (TECH FIG 2F).
■ The hand and forearm are immobilized with a splint for 6 days.

TECH FIG 2 • A. The venae comitantes are preferred
for venous outflow of the radial forearm flap. Using the
cephalic vein may unnecessarily take a wider flap or
render the cephalic vein along the edge of the flap. B.
A small exploratory incision is made first at the wrist
crease to ensure one of the venae comitantes is at
least 1 mm in diameter for adequate venous outflow.
C. Suprafascial dissection can avoid tendon exposure
and preserve the thenar branch of the radial sensory
nerve. D. For submandibular dead space filling, some
adipofascial tissue is recruited from the proximal

forearm. E. This adipofascial tissue can also be based
on a proximal perforator. F. With suprafascial
dissection and full-thickness skin grafting following a
radial forearm flap harvest, an excellent donor site can
be achieved.
Ulnar Artery Perforator Flap
■ The use of the ulnar artery perforator flaps creates a more favorable donor
site compared with harvest of the radial forearm. It is also less hairy and
slightly thicker but as pliable as the radial forearm flap.3 It has become the
author’s preferred flap for partial glossectomy reconstruction unless a very
thin thigh flap is available.
■ The pedicle length of the ulnar artery perforator flap is much shorter. The
length of the radial forearm flap pedicle is not typically necessary for
hemiglossectomy reconstruction unless the recipient vessels are the
transverse cervical vessels, and the shorter pedicle length of the ulnar artery
perforator flap may be desirable to avoid kinking.
■ A line is drawn between the pisiform and the medial epicondyle, which
corresponds to the septum between the flexor digitorum superficialis (FDS)
and flexor carpi ulnaris (FCU) muscles in which the ulnar neurovascular
bundle travels.
■ The distal border of the flap is designed 5 cm above the wrist crease to avoid
tendon exposure (TECH FIG 3A).
■ Dissection is performed under tourniquet control.
■ The radial and distal borders of the flap are incised first.
■ Suprafascial dissection is performed toward the ulnar side until the
perforators are seen emerging between the FDS and FCU muscles (TECH
FIG 3B).
■ The fascia over the FDS is then incised, and subfascial dissection is carried
out (TECH FIG 3C). The perforators are small; thus meticulous dissection is
required.
■ The locations of the perforators are marked on the skin surface with a 5-0
Prolene suture.
■ The ulnar nerve travels with the vascular pedicle closely together for the
majority of its length. The vascular pedicle is carefully separated from the

ulnar nerve, and retraction of the nerve should be avoided.
■ One should never be rough to the ulnar nerve during dissection. Any
traction should be applied to the vascular pedicle, not to the nerve.
■ Small vascular branches to the neighboring muscles are clipped and
divided.
■ The use of electric cautery should be avoided as these vessels are very
close to the ulnar nerve.
■ Proximally, the vascular pedicle takes a turn radially away from the ulnar
nerve (TECH FIG 3D).
■ Several muscular branches are divided to reveal the bifurcation with the
common interosseous artery.
■ The median nerve and its branches can also be seen (TECH FIG 3E). Any
traction to these nerves should be avoided.
■ The venae comitantes usually do not converge, but each vein should have a
diameter 2 to 3.5 mm, more than adequate for venous outflow.
■ The authors use the venae comitantes exclusively instead of superficial
veins and have not encountered any venous outflow issues.
■ The medial antebrachial cutaneous nerve is included in the flap for sensory
reinnervation (TECH FIG 3F).
■ A small segment of the FCU muscle can be included for dead space filling
if an adipofascial flap cannot be obtained in very thin patients (TECH FIG
3G).
■ Once the vascular pedicle is isolated, the tourniquet is released to perfuse the
flap and hand before dividing the vascular pedicle. Donor site care is the
same as radial forearm flap.

D B

TECH FIG 3 • A. The ulnar artery perforator flap is
designed with the distal border 5 cm proximal to the
wrist crease to avoid tendon exposure. B.
Suprafascial dissection is performed ulnarly until the
ulnar artery perforators emerging between the FDS
and the FCU muscles are identified. C. The fascia is
then incised; the subfascial dissection proceeds
ulnarly to expose the ulnar neurovascular bundle. D.
In the proximal forearm, the ulnar vessels (yellow
arrow) take a radial turn away from the ulnar nerve
(white arrow). The bifurcation of the ulnar artery with
the common interosseous artery is then reached,
which is the limit of the pedicle dissection. The median
nerve and its branches can be seen at this level.
Traction on the nerve should be avoided. E. The
medial antebrachial cutaneous nerve (yellow arrow)
can be included for sensory reinnervation. A small
segment of the FCU muscle (white arrow) can be
included for submandibular dead space filling if
needed. F. A thin anterolateral thigh flap is another
good option for hemiglossectomy reconstruction. G.
Various amounts of vastus lateralis muscle can be
included for dead space filling.
Anterolateral Thigh Flap
■ In thin patients, the anterolateral thigh flap can also be used for
hemiglossectomy reconstruction. Flap dissection is performed as previously
described by the author.4–6
■ To fill the submandibular dead space, various amounts of the vastus lateralis
muscle are included in the flap (TECH FIG 4A).
■ Primary thinning of the flap periphery can reduce bulk for hemiglossectomy
reconstruction.
■ The lateral femoral cutaneous nerve of the anterolateral thigh flap can be

included for sensory reinnervation (TECH FIG 4B).7
■ Additional thigh-based options including anteromedial thigh8,9 and profunda
artery perforator flaps are feasible but generally too thick for
hemiglossectomy reconstruction.
TECH FIG 4 • A. The lateral femoral cutaneous nerve
(arrow) of the anterolateral thigh flap is used for
sensory reinnervation. B. The harvested flap, showing
with the vascular pedicle and lateral femoral
cutaneous nerve (yellow arrow).
■ Flap Inset
■ The distal end of the flap is oriented toward the tip of the remaining tongue.
■ The width of the distal flap lines up with the ventral surface of the
remaining tongue from the tip to the frenulum attachment of the
mandibular gingiva.
■ The two distal corners of the flap are anchored to these two structures, and
the rest of the flap is draped over the glossectomy and floor of mouth
defects toward the posterior limit of the defect.
■ Extra flap is trimmed to fit the defect.
■ Flap insetting starts from the posterior end of the defect, either at the base of
the tongue or above the epiglottis.
■ This part of flap insetting is completed through the neck exposure, before
vascular anastomoses are performed.
■ Once flap insetting reaches the mandible, one can either proceed with
vascular anastomosis or continue the insetting intraorally depending on the
surgeon’s preference and the ischemia time.

■ Intraorally, one lateral edge of the flap is sutured to the gingiva and the other
to the cutting edge of the remaining tongue.
■ The key step in flap insetting is to recreate the ventral sulcus of the
neotongue to avoid tethering.
■ The distal medial corner of the flap is sutured to the tip of the remaining
tongue.
■ The distal cutting end (the width) of the flap is sutured to the ventral
surface of the remaining tongue (TECH FIG 5A), thus creating a nice
ventral sulcus and lateral gutter (TECH FIG 5B).
■ Great care should be taken not to catch the lingual vessels as they travel
superficial and near the midline of ventral tongue (TECH FIG 5C).
■ A single layer of interrupted 3-0 Vicryl sutures is preferred by the authors,
although horizontal mattress sutures may be preferred by others in order to
create a watertight seal.
■ It is important, however, not to tie the horizontal mattress sutures too
tightly so as to avoid flap/mucosal edge necrosis leading to fistula
formation.
■ When there is no gingiva left to attach the flap to, the flap can be sewn to
the teeth by tying the suture knots around the teeth.
■ Once the flap is partially or completely inset, the flap pedicle is brought
under the mandible to the neck.
■ Meticulous care should be taken to avoid twisting of the pedicle.

TECH FIG 5 • A. The distal width of the flap is lined up
with the ventral surface of the tongue to recreate the
ventral sulcus. B. The rest of the flap is draped over
the glossectomy and floor of mouth defect to recreate
the lateral gutter. Both are important to prevent
tethering. C. The adipofascial flap from the proximal
forearm is just large enough to obliterate the
submandibular dead space.
■ When the lingual artery and common facial vein are used, the vascular
pedicle is longer than needed.
■ The pedicle should be carefully positioned with a gentle curve to avoid

kinking.
Sensory Reinnervation
■ The cutting end of the lingual nerve is freshened, and the sensory nerve from
the flap is coapted to the lingual nerve with several 8-0 nylon sutures.
■ This is usually done with loupe magnification, as the lingual nerve is
inaccessible to the operating microscope.
■ Sensory recovery of the flap with this technique has been well
documented, and therefore, sensory reinnervation is strongly
recommended.
■ After the vascular and nerve repairs are completed, the extra adipofascial
tissue or muscle from the flap is carefully positioned to fill the submandibular
space while avoiding pedicle compression (TECH FIG 6).
TECH FIG 6 • The reconstructed tongue should be
able to lift and touch the palate without tethering. This
is important to achieve intelligent speech.
■ Closure
■ The oral cavity is irrigated with normal saline until clean.
■ The neck wound is then irrigated with an ample amount of warm normal

saline, taking care not to squirt the saline directly on the vascular pedicle to
avoid vessel spasm.
■ Meticulous hemostasis is essential to avoiding a postoperative hematoma,
which can compress the vascular pedicle. All areas should be carefully
examined for hemostasis, especially in the neck dissection field, even if they
have already been examined by the ablative surgeons.
■ A 15 Fr Blake drain is placed in the neck, lateral to the internal jugular vein.
■ At this point, the neck is slightly flexed (take out the shoulder roll and flex
the neck to a neutral position), and the vascular pedicle is examined again.
■ Because the neck is usually hyperextended and turned to the opposite side
during surgery, returning the neck to a neutral position can significantly
change the position of the vascular pedicle, causing kinking or
compression.
■ The pedicle is repositioned if necessary to avoid such problems.
■ The neck incision is then closed.
■ Finally, the reinforced tracheostomy tube is replaced with a no. 6 Shiley
tube, if this has not been done already by the ablative surgeons.
PEARLS AND PITFALLS
Flap
selection
■ Determine the goals of reconstruction based on extent of remaining
native tongue. A hemiglossectomy defect should be reconstructed with a
thin, pliable flap that will preserve mobility of the tongue remnant.
Avoid
tethering
■ Adequate width of the distal flap (6 cm) is used to recreate the ventral
sulcus, and the remaining flap width (6–8 cm) is used to recreate the
lateral gutter. These steps are essential to avoid flap tethering that can
significantly impair function. The patient should be able to lift the tip of
the tongue to touch the palate after hemiglossectomy reconstruction
(FIG 22).
Flap
inset
■ Inset is mostly performed before microsurgical anastomoses to limit soft
tissue swelling and bleeding.
■ Circumdental sutures can be used if remnant gingiva is inadequate.
Closure
■ Discontinue neck hyperextension, and restore neutral positioning prior
to neck closure to ensure the absence of pedicle kinking.

POSTOPERATIVE CARE
■ In most cases, patients may be awakened from general anesthesia and
transferred to the surgical floor for flap monitoring.
■ The traditional convention of intensive care monitoring with prolonged
sedation and/or mechanical ventilation for head and neck reconstruction is
unnecessary unless medical indications arise. This approach significantly
expedites recovery and reduces cardiopulmonary morbidity.
■ Pulmonary toilet is improved with spontaneous respiration, and the
hemodynamic lability associated with continuous sedation is avoided.
■ Flap monitoring regimens are surgeon dependent, but the authors practice
hourly clinical examination of the intraoral flap for the first 48 hours as the
standard.
■ Pencil and/or implanted Doppler are used to supplement the monitoring
regimens as available or required.
■ Flap assessment is reduced to every 2 hours subsequently for the next 48
hours and to every 4 hours thereafter.
■ Delirium tremens prophylaxis should be given to patients with history of
alcohol abuse, which is prevalent among head and neck cancer patients.
■ History of substance abuse and narcotic dependence may predispose patients
to postoperative confusion and agitation and may lead to hypertension,
hematoma, anastomotic breakdowns, and avulsion of the vascular pedicle.
Prompt management of these issues with neuropsychiatric staff is important.
■ Enteral tube feeding is initiated on postoperative day 1.
■ Patients are allowed to mobilize starting on postoperative day 1 and
ambulating by postoperative day 2.
■ Broad-spectrum antibiotics such as ampicillin/sulbactam are usually continued
for 3 days or longer, as indicated.
■ A modified barium swallow study is performed by speech pathology typically
on postoperative day 7 to evaluate for swallow function, leak, and aspiration.
■ In patients with no leaks or aspiration, a liquid diet is started and then quickly
advanced to a soft or regular diet as tolerated. If the patient received previous
radiation, the swallow study may be deferred to 2 weeks after surgery.
■ Patients are typically discharged between postoperative days 5 and 7.
■ Oral hygiene is critical. Patients should rinse frequently with saline or Peridex
until the flap is well healed.
■ In patients with leaks or aspiration upon swallowing, oral intake is withheld,

and a modified barium swallow study is repeated in 2 weeks or longer, as
clinically indicated.
■ Tracheostomy downsizing, capping, and decannulation can be performed if
clinically tolerated once acute postoperative surgical site swelling is
diminished prior to discharge.
■ In high-risk patients, delayed decannulation or long-term tracheostomy
dependence may be indicated.
■ Outpatient follow-up with speech therapy to improve swallow and speech
function is beneficial.
OUTCOMES
■ The most important predictor of functional outcome is the extent of remaining
tongue. Good clinical and functional outcomes following hemiglossectomy
reconstruction have been reported.10–12
■ Speech intelligibility after hemiglossectomy reconstruction has been studied
using a standardized numeric speech therapy scale (4, greater than 80%
intelligible; 3, 50%–80% intelligible; 2, less than or equal to 50% intelligible;
1, unintelligible; and 0, inability to speak). Patients who underwent partial
glossectomy or hemiglossectomy had significantly superior speech function
(mean scores 3.59, 3.74, respectively) compared with patients with subtotal
glossectomy (3.14) or total glossectomy (2.42).
■ Successful sensory reinnervation of the radial forearm flap has been well
documented.13,14 Innervation was associated with better speech scores
following hemiglossectomy reconstruction (3.89 vs. 3.42).
■ Risk factors for poor swallowing function after glossectomy include age of 60
years or older and preoperative radiation.
■ Swallow function after hemiglossectomy reconstruction has been evaluated
based on type of diet tolerated (4, regular unrestricted diet; 3, soft diet; 2,
pureed or liquid diet; 1, oral diet requiring tube-feed supplementation; and 0,
tube-feed dependency).
■ Patients who underwent more extensive resections (total glossectomy, 0.83;
subtotal glossectomy, 1.49) had significantly worse swallow function than did
those who received only a partial glossectomy or hemiglossectomy (2.47).
■ Patients who received innervated flaps had superior swallowing outcomes
compared with patients who received noninnervated flaps in our experience,
but controversy exists surrounding this topic in the surgical community.

COMPLICATIONS
■ In the authors’ published experience, the overall 30-day complication rate
following microsurgical reconstruction for glossectomy was 23.6%. Total flap
loss rate was less than 1%.
■ Potential complications include the following:
■ Flap arterial or venous thrombosis
■ Partial or complete flap loss
■ Bleeding or hematoma
■ Infection or abscess
■ Flap dehiscence
■ Orocutaneous fistula
■ Respiratory complications including pneumonia
■ Aspiration
■ Altered or poorly intelligible speech
■ Inability to swallow or tolerate oral intake, feeding tube dependence
■ Tracheostomy dependence
■ Flap donor-site complications (skin graft failure, seroma, paraesthesia, etc.)
REFERENCES
1. Yu P. The transverse cervical vessels as recipient vessels for previously treated
head and neck cancer patients. Plast Reconstr Surg. 2005;115(5):1253-1258.
2. Selber JC, Sanders E, Lin H, Yu P. Venous drainage of the radial forearm flap:
comparison of the deep and superficial systems. Ann Plast Surg. 2011;66:347-
350.
3. Yu P, Chang EI, Selber JC, Hanasono MM. Perforator patterns of the ulnar
artery perforator flap. Plast Reconstr Surg. 2012;129:213-220.
4. Yu P. Characteristics of the anterolateral thigh flap in a Western population
and its application in head and neck reconstruction. Head Neck. 2004;26:759-
769.
5. Yu P, Youssef A. Efficacy of the handheld Doppler in preoperative
identification of the cutaneous perforators in the anterolateral thigh flap. Plast
Reconstr Surg. 2006;118:928-933.
6. Lin SJ, Rabie A, Yu P. Designing the anterolateral thigh flap without
preoperative Doppler or imaging. J Reconstr Microsurg. 2010;26:67-72.
7. Yu P. Reinnervated anterolateral thigh flap for tongue reconstruction. Head
Neck. 2004;26:1038-1044.
8. Yu P, Selber JC. Perforator patterns of the anteromedial thigh flap. Plast

Reconstr Surg. 2011;128:151e-157e.
9. Yu P, Selber JC, Liu J. Reciprocal dominance of the anterolateral and
anteromedial thigh flap perforator anatomy. Ann Plast Surg. 2013;70:714-716.
10. Chang EI, Yu P, Skoracki RJ, Liu J, Hanasono MM. Comprehensive analysis
of functional outcomes and survival after microvascular reconstruction of
glossectomy defect. Ann Surg Oncol. 2015;22:3061-3069.
11. Engel H, Huang JJ, Lin CY, et al. A strategic approach for tongue
reconstruction to achieve predictable and improved functional and aesthetic
outcomes. Plast Reconstr Surg. 2010;126:1967-1977.
12. Akashi M, Hashikawa K, Sakakibara A, et al. Long-term follow-up study of
radial forearm free flap reconstruction after hemiglossectomy. J Craniofac
Surg. 2015;26:44-47.
13. Boyd B, Mulholland S, Gullane P, et al. Reinnervated lateral antebrachial
cutaneous neurosome flaps in oral reconstruction: are we making sense?. Plast
Reconstr Surg. 1994;93:1350-1359.
14. Santamaria E, Wei FC, Chen IH, Chuang DC. Sensation recovery on
innervated radial forearm flap for hemiglossectomy reconstruction by using
different recipient nerves. Plast Reconstr Surg. 1999;103:450-457.

42
CHAPTER
Floor of Mouth
Reconstruction
George N. Kamel, J. Alejandro Conejero, and Evan Garfein
ANATOMY
■ The floor of mouth is a U-shaped mucosal structure covered by squamous
mucosa that is bordered by the alveolar ridge of the mandible and extends
posteriorly to the anterior tonsillar pillar (FIG 1A).
■ Medially, the floor of the mouth (FOM) merges with mucosal, ventral surface
of the tongue to the level of the frenulum, which divides the floor into two
oval spaces.
■ The FOM contents include the sublingual salivary glands, submandibular
ducts, oral component of the submandibular salivary gland, the geniohyoid and
genioglossus muscles, and the lingual and hypoglossal nerves.
■ The lingual nerve provides sensation to the FOM.
■ The arterial supply to the FOM is from the lingual arteries, branches of the
external carotid artery, as well as the mylohyoid and submental branches of the
facial arteries.
■ The mylohyoid and hypoglossus muscles provide both structural support to the
contents of the FOM and serve as barriers to the submental and submandibular
triangles of the neck (FIG 1B).
■ The sublingual salivary glands, located beneath the mucosa of the anterior
FOM, drain via the excretory ducts of Rivinus, which drains into the
submandibular duct or directly into the FOM through the plica fimbriata
(mucous membranes located on either side of the frenulum).
■ The anterior FOM lymphatic drainage is to the submental and submandibular
nodes, whereas the posterior FOM drains to the upper cervical lymph nodes.
PATHOGENESIS

■ Floor of mouth squamous cell carcinoma (SCC)
■ Approximately 18% to 45% of all oral SCCs occur in the FOM, and most
originate at the anterior midline.1 As with other locations of oral SCCs, there
is a strong association with alcohol consumption and tobacco smoking. There
is an increasing incidence of HPV-associated head and neck SCCs in patients
without traditional risk factors.
■ SCC tumors typically spread in a superior or horizontal fashion as the
muscular floor of the FOM serves as a barrier to tumor spread. However,
these tumors can also invade the submucosa, the intrinsic tongue muscles, and
the contralateral space in the FOM.
■ The location of FOM structures and their association with the tumor affects
the presentation of tumor invasion. In certain cases, SCCs may obstruct the
ostia of the submandibular duct, which is located along either side of the
frenulum resulting in inflammatory changes and ductal dilatation. In contrast,
the sublingual glands are more prone to direct invasion due to proximity of
the tumor. Invasion of the mandible upstages the tumor.
■ Cervical lymph node invasion is common at time of diagnosis, and
hematogenous spread to distant sites including the liver, bones, and lungs
must be ruled out.
■ Floor of mouth salivary gland tumors and sarcomas
■ These tumors account for 3% to 5% of all head and neck cancers, most
commonly appearing in the sixth and seventh decade of life.
FIG 1 • Anatomy (A) and musculature (B) of the FOM.

■ The etiology is multifactorial; however, occupations with an associated
increased risk include mining, asbestos exposure, and rubber manufacturing.
■ The most common of these tumors are adenoid cystic carcinoma and
mucoepidermoid carcinoma.
■ Most patients present with a painless slow-growing mass. Others may
manifest with perineural invasion resulting in pain or numbness.
■ Sarcomas of the oral cavity most often arise from the maxilla or mandible as
an osteosarcoma, chondrosarcoma, rhabdomyosarcoma, or liposarcoma.
Liposarcomas occur with equal frequency in the mandible and maxilla.
Similar to other neoplasms of the oral cavity, surgical resection is the primary
modality for treatment.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patient history begins with a thorough assessment of the onset of symptoms,
duration, course, and associated risk factors, the most common of which are
alcohol consumption and tobacco use.
■ Symptoms of floor of mouth tumors may include an enlarging or recurrent
mass, difficulty with speech, chewing or deglutition, odynophagia, halitosis,
and red or white intraoral discoloration.
■ The physical exam begins with inspection and palpation of both the extraoral
and intraoral soft tissues. This includes assessment of the lips, intraoral labial
mucosa, buccal mucosa, the dorsal and ventral surface of the tongue, the hard
palate, and the FOM.
■ The sublingual, submandibular, and parotid glands are palpated and examined
for any abnormalities.
■ The neck is inspected for signs of cervical lymphadenopathy as floor of mouth
cancers typically metastasize to the cervical chain of lymph nodes. Evaluation
of the anterior deep cervical lymph nodes, the preauricular and postauricular
lymph nodes, is included in the examination.
IMAGING
■ Numerous imaging modalities are available for both diagnostic as well as
treatment planning and include plain radiographs, magnetic resonance imaging
(MRI), computed tomography (CT), and positron emission tomography (PET).
■ Plain radiographs or panoramic images are routinely used by dentists and may
initially suggest a malignant lesion during an initial evaluation. CT scans,
however, are currently the standard for primary tumor detection with a

specificity ranging from 81% to 100% and sensitivity of 41% to 82%.
■ PET scan or PET/CT evaluates tissue metabolic activity and is used to assess
for metastatic spread to lymph nodes as well as distant tissues.
SURGICAL MANAGEMENT
■ Successful reconstruction after oncological extirpation is based on the
following principles:
■ Tumor-free resection margins
■ Maximizing mobility of the remaining tongue
■ Watertight closure and seal that protects the neck structures from FOM
secretions
■ Maintaining mandibular continuity
■ Reconstructive options
■ FOM defects arise most frequently from composite resections of the mandible
and FOM or tongue and FOM. Less frequently, resection of soft tissue tumors
or salivary gland cancers leads to isolated FOM defects.
■ Many options exist for reconstruction of the soft tissue FOM defects. In
general, the reconstructive options are dictated by the volume and type of
tissue that is resected. Thus, soft tissue low volume defects require replacement
with low volume soft tissue flaps. Large-volume composite defects that include
soft tissues and bone may require reconstruction with osteocutaneous flaps.
Rarely, complex cases may require more than one flap for reconstruction;
however, in general, most defects of the FOM can be reconstructed with a
single flap.
■ Microvascular free flaps are the preferred reconstructive options for patients
with floor of mouth defects because they have excellent blood supply; can be
constructed of thin, pliable tissue; and can be customized to fit any defect.
■ Soft tissue flaps such as the radial forearm, anterolateral thigh (ALT), medial
sural artery perforator flap (MSAP) and pectoralis major musculocutaneous
flaps are most commonly used for FOM reconstruction. The selection of
reconstructive technique depends on patient factors, the extent and complexity
of the surgical resection, and surgeon preference.
■ Patient factors include thickness of the subcutaneous fat layer in the flap
donor sites and blood supply/circulation (eg, intact palmar arch).
■ Surgical factors include primarily the type and extent of resection. For
example, complex defects that include wide resection of the FOM
musculature and supporting structures may require a large volume composite

flaps that include skin and muscle to obliterate dead space, whereas low-
volume defects restricted to the FOM mucosa may be better reconstructed
with thin pliable flaps.
■ Ultimately, the flap that is selected for reconstruction should maximize
reconstructive goals of obtaining a watertight closure of the defect and
maximize the potential to swallow and speak.
Soft Tissue Flap Options
■ Radial forearm fasciocutaneous free flap
■ The radial forearm flap was first described by Yang in 1981 and later
popularized by Soutar and McGregor in 1986 for intraoral reconstruction and
is a skin and fascial flap based on the radial artery, its venae comitantes, and,
often, the cephalic vein.2
■ It is considered the workhorse for many soft tissue head and neck defects and
is adequate for moderate to large FOM defects.
■ It is pliable, thin, and has a long vascular pedicle measuring (10–15 cm). One
may incorporate a portion of the radius bone or palmaris tendon if needed for
reconstruction.
■ The superficial branch of the radial nerve lies adjacent to the radial artery,
and this branch supplies sensation to the dorsal aspect of the thumb and index
finger. This branch should be preserved during dissection of this flap.
■ The skin paddle of the radial forearm flap is supplied by fasciocutaneous
branches of the radial artery, with venous drainage through the superficial
cephalic vein and the deep venae comitantes.
■ Sensory innervation to the FOM can be restored in some cases by
anastomosing the lateral antebrachial cutaneous nerve in the flap to the lingual
or inferior alveolar nerves in the recipient site.3
■ The anatomical location of the radial forearm flap allows for simultaneous
harvest by the reconstructive team at the time of tumor extirpation.
■ Disadvantages of the radial forearm flap include decreased circulation to the
hand, risk of tendon exposure, radial nerve injury, painful neuroma, cold
intolerance, and possible poor cosmetic result.
■ Anterolateral thigh flap
■ The ALT flap, first described by Song in 1984 and further advanced by Wei,
is a soft tissue perforator flap based on the descending branch of the lateral
circumflex femoral artery (DLCFA), the largest branch of the profunda
femoris.4,5

■ The ALT flap has a long pedicle, ranging from 7 to 16 cm with reliable
septocutaneous or musculocutaneous perforators arising from the descending
branch of the LCFA.
■ The location of the flap allows for simultaneous harvest at the time of tumor
extirpation.
■ The ALT flap has minimal donor site morbidity as one of its principal
advantages and is an optimal choice for large volume complex defects of the
FOM because it can be harvested with vascularized fascia and muscle if
necessary.
■ Disadvantages to the ALT flap include variable anatomy and location of the
perforators. It should be avoided in small intraoral defects due to the
potential increased bulk of this flap.
■ Medial sural artery perforator flap
■ The MSAP flap was first described by Cavadas in 2001 for reconstruction of
distal limb defects. In 2008, Chen introduced the MSAP free flap for intraoral
reconstruction following cancer ablation.6
■ The MSAP flap is, in most patients, thin and pliable, suitable for intraoral
defects.
■ The MSAP flap is associated with minimal donor site morbidity, and its
locations allow for simultaneous harvest at the time of tumor extirpation.
■ The disadvantage of the MSAP flap is in the difficulty of identifying a
reliable cutaneous perforator that may at times be mistaken for a muscular
branch of the medial sural vessels.
■ Pectoralis major musculocutaneous flap
■ The pedicled pectoralis major musculocutaneous flap first described by
Ariyan in 1979 was considered the workhorse for oropharyngeal defects prior
to the advancements made in free vascularized tissue transfer.7
■ The pectoralis major musculocutaneous flap is now most often used as a
salvage flap in FOM reconstruction. The pectoralis major musculocutaneous
flap is also useful in patients who are poor candidates for vascularized free
tissue transfer or those with large defects who require two flaps for
reconstruction.
■ The disadvantages include a contour defect, slight loss of arm adduction and
rotation provided by the pectoralis major muscle, and added bulk in the neck
caused by the pedicled muscle.

T E C H N I Q U E S
■ Floor of the Mouth Reconstruction With a Radial
Forearm Free Flap
Preparation of the Recipient Site
■ The defect is carefully analyzed to understand the extent of the resection and
the tissues necessary for reconstruction.
■ Specifically, attention is paid to the extent and pattern of mucosal defect as
well as the volume of the defect created by resection of the FOM
musculature/soft tissues (TECH FIG 1).
■ If a microvascular free flap is planned, recipient vessels in the neck are
identified, dissected, and made ready for microvascular anastomosis.
■ In patients who have had a previous neck dissection or radiation therapy,
assessment of arterial inflow should be done. In most cases, however, the
quality and patency of the vessels are easily assessed during the dissection.
TECH FIG 1 • Floor of mouth defect after partial
tongue, FOM, and marginal mandibulectomy.